Resident Education Perspective
Lessons of History:
Benjamin R. Gray, MD, Richard B. Gunderman, MD, PhD
Key Words: Visualization; localization; medical gaze; Foucault.
© 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
F
or a fish, one of the most difficult things to notice is
the fact that it spends every moment of every day in
water. Water is such a ubiquitous and ever-present
feature of its experience that it goes through its days unaware
of this utterly pervasive feature of its daily life. Something similar
can happen to human beings, for whom constant features of
daily experience can prove difficult to recognize and there-
fore difficult to understand with any degree of depth. The
18th-century philosopher Immanuel Kant famously sug-
gested that space and time represent two such underappreciated
facets of experience (1).
Radiology and radiologists are in a similar boat, at least when
it comes to the role of “seeing” in the contemporary prac-
tice of medicine. Anyone who knows anything about radiology
recognizes that it is an inherently visual field. The role of vision
in the field is so central that to speak of a blind radiologist
would be oxymoronic. Throughout each workday, the ra-
diologist uses the power of vision to inspect images of the
interior of the human body, attempting to detect and char-
acterize the telltale signs of health and disease.
But built into this approach to medical diagnosis is a wealth
of assumptions that many radiologists have barely paused long
enough to recognize, let alone ponder or critically inspect.
To see these assumptions for what they are, it is necessary to
look at medicine through the lens of history. There was a
time when our current way of thinking about health and disease
was radically new. To understand this paradigm in depth, we
need to see it anew, by gaining some insights into both the
paradigm it replaced and the nature of the replacement it
represented.
In his book, The Birth of the Clinic, French historian Michel
Foucault argues that a radical transformation took place in med-
icine in the late 18th century (2). This shift involved a change
in medical perception, as indicated by the book’s subtitle, An
Archaeology of Medical Perception. The central concept here is
Acad Radiol 2016; 23:774–776
Department of Radiology, Indiana University, 702 North Barnhill Drive, Room
1053, Indianapolis, Indiana 46077 Received January 17, 2016; accepted January
18, 2016. Address correspondence to: R.B.G. e-mail: rbgunder@iupui.edu
© 2016 The Association of University Radiologists. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.acra.2016.01.016
774
The Medical Gaze
what Foucault calls the “medical gaze,” which refers to the
way the physician observes the patient, including the various
features of disease that the sick person may demonstrate (2).
According to Foucault, in the 18th century, physicians began
to see patients very differently (3).
One crucial assumption here is that perception is not a strict-
ly physiological or even psychological phenomenon. The
cornea, lens, and retina, optic nerve, and visual cortex all play
a vital role in enabling us to see, but what we in fact see is
also affected by how we look and what we expect to find.
The spirit of this point of view is well captured in the adage,
“You only find what you look for.” Foucault believes that
our vision is shaped by historical and cultural factors, and that
physicians in the 17th and 19th century literally perceived their
patients in radically different ways (4,5).
What, precisely, was the nature of this shift? This ques-
tion is best answered with respect to the questions physicians
put to their patients. At the beginning of the 18th century,
physicians tended to ask their patients, “What is the matter
with you?” (3). The expectation was that the patient would
describe some disruption or alteration in their daily experi-
ence, such as difficulty breathing or walking. The idea was
that disease involved the whole person, and that to under-
stand what was ailing a patient, it was necessary to take the
whole person into account.
Beginning at some point in the late 18th century, Fou-
cault argues (3), physicians ceased asking, “What is the matter
with you?” and began asking, “Where does it hurt?” Of course,
Foucault is not so naïve as to assume that pain is the only
symptom of disease, but by this new question he means to
suggest that the gaze of the physician had shifted from the
whole patient to particular parts of the patient. That is, phy-
sicians began thinking of disease in terms of a process that must
be localized to be understood (2). Disease, in other words,
acquired an address within the patient’s body.
To a radiologist, this shift might seem virtually incompre-
hensible. After all, every radiologist alive today has been deeply
steeped in the idea that disease not only can be but by and
large must be localized to be understood. Where is the cancer—
in the lung, the colon, or the breast? Where is the infection—in
the appendix, the gallbladder, or the kidney? Every time ra-
diologists look at images we are looking at organs and tissues
Academic Radiology, Vol 23, No 6, June 2016
in which we assume disease can and must reside, and our
mission is to locate the disease.
Of course, there are exceptions, and these are by and large
the very areas of medicine in which radiologists traffic least.
Leukemia, for instance, can threaten a patient’s life yet produce
no lesions that a radiologist can identify on a cross-sectional
imaging study. The same can be said for a variety of psychi-
atric disorders, whose pathology cannot, as yet, be localized
to any particular anatomic structure. Some disorders in which
no localizable lesion has been identified, such as fibromyalgia
and chronic fatigue syndrome, cling to the very margins of
medical legitimacy.
For Foucault, in others words, the spatial dimension of
disease, as manifest in “pathological anatomy,” takes on a huge
new importance in the 18th century, a significance that per-
sists down to the present day (6). This new interest is manifested
by the efflorescence of the autopsy, which seeks to find in
the anatomy of the corpse the site of the disease process that
took the patient’s life (6). Symptoms remain important, but
not primarily in their own right but insofar as they make it
possible to determine where to look.
Writes Foucault:
Disease is no longer a bundle of characters disseminated
here and there over the surface of the body and linked to-
gether by statistically observable concomitances and
successions; it is a set of forms and deformations, figures,
and accidents and of displaced, destroyed, or modified el-
ements bound together in sequence according to a
geography that can be followed step by step. It is no longer
a pathological species inserting itself into the body wher-
ever possible; it is the body itself that has become ill. (6)
It is hard for many radiologists to believe, but prior to the
development and ascendancy of pathologic anatomy, the very
idea of localizing a lesion was not a priority in the under-
standing of disease process. Nor was it important to locate
the site of origin or activity of a disease. To repeat, it was
only in the 18th century that disease in general acquired an
anatomic address. To be sure, no one denied that it was im-
portant to understand which part of the body had been injured,
but most diseases were not perceived as localizable processes.
The shift that takes place in the 18th century is even more
radical than this. With the shift in the medical gaze, “the space
of configuration of the disease and the space of the localiza-
tion of the illness in the body have become superimposed”
(2). That is, the mental or psychological space in which disease
is understood to operate becomes coextensive with the dif-
ferent parts of the human body. Textbooks of medicine begin
to be organized in organs and organ systems, and physicians
become preoccupied with identifying the “localization, site,
and origin of illnesses” (6).
Medicine becomes an act of seeing, or at least searching
visually, for the anatomic disease, and what is true of med-
icine in general is truest of all of the work of radiologists. To
practice radiology is to inspect, to examine the anatomy of
the patient visually, focusing not on the body itself but on
LESSONS OF HISTORY
its anatomy as revealed by various imaging modalities. Once
disease becomes conceptually localizable in a part of the body
and images can be made of body parts, medicine gains in fields
such as pathology and radiology the ability to diagnose disease
despite the absence of the patient.
The aspect of the patient that matters most is no longer
the aspect that talks, thinks, and feels, the one that can be in-
terviewed and examined, but the aspect that can be abstracted
from the patient, such as a pathologic specimen or a radio-
logic image. What meets the eye in direct inspection, the ear
in taking a history, and the hand in palpation gives way to a
keen interest in the patient’s interior, the parts that cannot
be directly interrogated by the senses. With radiology, such
inner structures become accessible to the eye without the use
of a scalpel.
Radiology could not exist without the discovery and in-
novation of new imaging modalities made possible by the
work of giants such as Roentgen, Curie, Hounsfield, and
Lauterbur, but it would be equally and perhaps even more
inconceivable without the transformation in the medical gaze
heralded by the paradigm shift in medicine toward patho-
logic anatomy and the localization of disease (7–10). In fact,
the imaging modalities, for all their importance, are mere
tools in comparison with the intellectual and cultural shift
that Foucault describes.
When we produce or inspect a radiology report, we are
encountering the work of a physician deeply steeped in the
paradigm of visual localization, to an even greater degree than
other physicians such as internists and psychiatrists. For ra-
diology, more than most other medical specialties, there is a
sharp distinction between the seer and the seen, the radiol-
ogist and the patient. So great is this divide that in many cases,
radiologists could not identify the photograph of a patient whose
radiologic images they just interpreted.
Because the radiologist is often dealing not with the patient
but with the patient’s anatomy as represented by imaging mo-
dalities on a computer monitor, the radiologist operates at a
particularly high degree of abstraction. Perhaps even more than
pathology, which still has its autopsies in which the physi-
cian directly encounters the patient’s body, radiology is perhaps
the most representational of all medical fields, where the ra-
diologist encounter a likeness or representation of the patient
and not patients themselves.
This representational approach introduces yet another degree
of separation between patients and physicians. This creates
special challenges for radiology, and in particular for radiolo-
gists, who are less likely than even radiologic technologists
to interact face-to-face with patients. Just as the radiologist
often never meets the patient, so the patient often never meets
the radiologist, which makes radiology one of medicine’s most
distant and ill-defined medical specialties, at least from the
patient’s point of view.
When we talk about the invisibility of radiologists to pa-
tients and referring health professionals, we are not talking
about a strictly 21st-century phenomenon. The seeds for such
separation were sown long before the advent of picture
775
GRAY AND GUNDERMAN
archiving and communication systems (PACS). They extend
all the way back to the 18th century, when physicians began
to see patients and their diseases in a radically new way, one
that only opened up vast new vistas in the medical percep-
tion and understanding of disease, but which also bequeathed
to medicine—and in particular, to radiology—a host of
challenges.
REFERENCES
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of pure reason. London: Penguin Classics, 1997; 59–84.
2. Foucault M. Chapter 1: Spaces and classes. In: Sheridan A, trans. The
birth of the clinic: an archeology of medicine experience. New York: Vintage,
1994; 3–21.
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